BACKGROUND AND PURPOSE:

• Zuckerwise et al. (AJOG, 2020) examined the outcomes of patients with antenatal diagnosis of placenta percreta managed with delayed vs immediate cesarean hysterectomy

METHODS:

• Retrospective study (2012 to 2018)
• Participants
  • Antepartum diagnosis of severe PAS (placenta percreta/ increta) at a single academic institution
• Interventions
  • Scheduled cesarean delivery at 34–35 weeks gestation and immediate hysterectomy
  • Cesarean delivery and delayed hysterectomy
• Delayed hysterectomy
  • Intraoperative multidisciplinary decision-making | If MFM and gyn onc consider risk in a particular case to be excessive, then placenta left in situ | Decision based on the extent of parametrial invasion (intraoperative observation)
  • Hysterotomy using fetal surgery technique: Stay sutures placed through the uterine wall | Small hysterotomy made with electrocautery | Membranes entered | Full-thickness, running, locking chromic suture to secure the membrane to the uterine wall | Surgical stapler to extend incision | Following delivery, hysterotomy closed with a full-thickness, running, locked delayed absorbable suture
  • Hysterectomy was planned for 4–6 weeks after delivery with preop MRI to confirm placental regression
• Data collection
  • Demographics | Maternal comorbidities | Time to interval hysterectomy | Blood loss | Need for transfusion | UTI injury and other maternal complications | Maternal and fetal mortality rates

RESULTS:

• 34 patients with severe PAS
  • Delayed hysterectomy:  14 patients
    • 9 as scheduled | 5 before the scheduled date
    • All cases confirmed percretra
  • Immediate cesarean hysterectomy: 20 patients
    • Intraoperative assessment of resectability: 16 patients  
    • Preoperative or intraoperative bleeding: 4 patients  
    • Percreta: 9 patients (45%) | Increta: 11 patients (55%)
• Median estimated blood loss was significantly lower with delayed hysterectomy
  • Immediate hysterectomy: 3000 mL (2375 to 4250 mL)
  • At time of delayed hysterectomy: 750 mL (650 to 1450 mL; P<0.01)
  • Sum total for delivery plus delayed hysterectomy: 1300 mL (70 to 2150 mL; P=0.037)
• Median units of transfused packed RBCs was lower at delayed hysterectomy (P<0.01)
  • Immediate cesarean hysterectomy: 4 units (2 to 8.25 units)
  • Delayed cesarean hysterectomy: 0 (0 to 2 units)
• Need for transfusion of ≥4 RBC units was lower in the delayed group (P=0.016)
  • Immediate hysterectomy: 9 patients (45%)
  • Delayed hysterectomy: 2 patients (14.2%)
• Maternal deaths: 1 in each group
  • Immediate hysterectomy: 5%
  • Delayed hysterectomy: 7%

CONCLUSION:

• Delayed hysterectomy for patients with an antenatal diagnosis of placenta percreta may reduce the amount of blood loss and the need for large blood transfusions vs immediate hysterectomy
• The authors suggest that delayed hysterectomy may
  • Allow time for uterine blood flow to decrease
  • Give the placenta time to regress from surrounding structures

Learn More – Primary Sources:

Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum

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Does Prenatal Diagnosis of Placenta Accreta Help Reduce Adverse Perinatal Outcomes?

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